Nutrition, Physical Activity and Smoking Habit in the Italian General Adult Population: CUORE Project Health Examination Survey 2018-2019.

BACKGROUND: Tobacco consumption, incorrect nutrition and insufficient physical activity/sedentariness represent modifiable NCDs risk factors in Western countries. To evaluate recent lifestyle indicators in Italy, data from the national Health Examination Survey (HES), implemented in 2018-2019 within the CUORE Project, were assessed. METHODS: Age-sex standardized results from random samples of Italian general population (35-74 years) were reported by sex, age-class, educational level and geographical area. From 2106 participants, 2090 were considered for smoking habit, 2016 for physical activity and 1578 for nutrition. Standardized questionnaires were used for smoking habit and physical activity, and the EPIC questionnaire for nutrition. RESULTS: Total cigarette current smokers were 23% in men and 19% in women; sedentariness during leisure time was 34% in men and 45% in women and at work 45% and 47% in men and women, respectively. Prevalence of balanced eating behaviours for vegetables was 28% in men and 39% in women; and for fruits 50% and 52%, respectively; prevalence of correct lifestyle (not smoker, regular physical activity and following at least five correct eating behaviours) was 7% and 12% for men and women, respectively. CONCLUSIONS: In 2018-2019, levels of unhealthy lifestyles were found to be still epidemic and basically stable compared to 10 years earlier (slight smoking habit decrease, slight sedentariness increase and slight nutrition improvements); intersectoral strategies and monitoring need to be continued.

Trends of overweight, obesity and anthropometric measurements among the adult population in Italy: The CUORE Project health examination surveys 1998, 2008, and 2018.

BACKGROUND/OBJECTIVES: Obesity is associated with an increased risk of noncommunicable diseases, such as diabetes, coronary heart disease, stroke, cancers, and conditions, including obstructive sleep apnea and osteoarthritis. Obesity is largely preventable, and halting its rise is one of the World Health Organization Global Action Plan for the Prevention of Noncommunicable Diseases targets. This study aimed to assess trends of anthropometric measurements in Italy using the data collected within the CUORE Project health examination surveys (HESs) 1998, 2008, and 2018. SUBJECTS/METHODS: Within the HESs 1998-2002, 2008-2012, and 2018-2019, anthropometric measurements were collected in random samples of the resident population aged 35-74 years, stratified by age and sex, from 10 Italian Regions in Northern, Central, and Southern Italy (2984 men and 2944 women, 2224 men and 2188 women, 1035 men and 1065 women, respectively). Weight, height, and waist and hip circumferences were measured using standardized methodologies. A standardized questionnaire was used to collect data on education. Indicators were age standardized. RESULTS: For both men and women, mean body mass index in 2018 was comparable with those in 1998 and 2008 (in 1998, 2008, and 2018-men: 26.7, 27.5, and 27.0 kg/m2; women: 26.2, 26.6, and 26.3 kg/m2). In 1998, 2008, 2018 prevalence of overweight resulted 49%, 47%, 46% in men and 33%, 32%, 28% in women respectively; prevalence of obesity resulted 17%, 24% 20% in men and 19%, 23%, 23% in women respectively. All indicators of excess weight worsen with increasing age and are more severe in persons with a lower educational level. CONCLUSIONS: Although the overall trend of excess weight over the past two decades appeared to be substantially stable in the Italian adult population, the continuous strengthening of undertaken initiatives should continue since there remains a high proportion of overweight or obesity and a gap between educational levels.

The methodology of the Italian Health Behaviour in School-aged Children (HBSC) 2018 study and its development for the next round.

Introduction: The Italian "Health Behaviour in School-aged Children" (HBSC) is a national surveillance system that collects data on health and well-being among adolescents aged 11, 13 and 15 years attending school. It is part of the HBSC Research Network, an international alliance of researchers from 45 European and North American countries and regions started in 1982. Methods: All countries and regions participating in HBSC must adhere to a common international standard protocol developed and systematically updated by the entire HBSC Network. Data collection occurs every four years. Italy joined the international Network in 2000 and, to date, five waves (in 2002, 2006, 2010, 2014 and 2018) have been carried out. From 2010 the Italian HBSC is representative at regional level and in 2017 the base of the "Surveillance system for risk behaviours in 11-17 year-olds" became part of the Prime Ministerial Decree "Identification of surveillance systems and registries of mortality, tumours and other diseases". Cluster sampling is used, with school class as primary sampling unit, and two validated questionnaires are used to collect the information. Results: In 2018, the Italian HBSC involved 3,608 classes and 58,976 students. The average response rates were 86% of sampled classes and 97% of students achieving a national and regional representative sample for youths of all age groups (19,504 eleven-year-old, 20,554 thirteen-year-old and 18,918 fifteen-year-old). The national coordination group prepared a standardized format for disseminating the results locally and indicating areas for intervention A national report and some articles have been published. The next round, which will take place in the 2021-2022 school year, will also involve a representative sample of students of grade four of secondary schools (adolescents aged 17 years) and use on line questionnaires. Conclusions: Over 3 decades at international and 2 decades at national level 35 years have demonstrated that HBSC methodology and its results are useful for monitoring and deepening the knowledge on the most critical issues of adolescents' well-being.

[Smoking initiation in Italian regions, 2014, and Regional Prevention Plans]. / Iniziare a fumare nelle regioni italiane nel 2014 e Piani Regionali di Prevenzione.

OBJECTIVES: to evaluate smoking prevalence in adolescents by Italian region from the Health Behaviour Study in School-aged Children (HBSC) of 2014 and to correlate it with the presence, in the 2014-2018 Regional Prevention Plans (PRPs), of school-based smoking prevention interventions. SETTING AND PARTICIPANTS: the 2014 HBSC surveillance system provided data on 48,000 adolescents aged 11, 13, and 15 years; Ministry of Health provided data for each PRP on interventions with a tobacco control component and, among them, school-based smoking prevention interventions. MAIN OUTCOME MEASURES: weekly smoking prevalence; proportion of school-based smoking prevention interventions out of prevention interventions with tobacco control measures. RESULTS: regions with the highest weekly smoking prevalence were Sardinia and Apulia for all age groups, Abruzzo for 11- and 15-year-old children, Basilicata for 15-year-old children, Bolzano for girls aged 13 years old; Liguria for females, Molise, Calabria, and Veneto for males. In the regions with the highest prevalence of smoking in 2014, in girls aged 11 and 13 years (Sardinia, Apulia, Basilicata, Liguria, Bolzano), a greater proportion of school-based smoking prevention interventions to be developed in the period 2014-2018 have been recorded. CONCLUSIONS: smoking prevalence in Italian adolescents is high, especially in 15-year-old children. Implementing policies recommended by the World Health Organization - Framework Convention on Tobacco Control (higher tobacco taxes, anti-tobacco mass media campaigns, plain tobacco package) could work synergistically with school-based interventions in order to decrease tobacco initiation among adolescents in Italy.

Prevalence of tobacco smoking and electronic cigarette use among adolescents in Italy: Global Youth Tobacco Surveys (GYTS), 2010, 2014, 2018.

This research aims to study tobacco smoking and vaping among adolescents in Italy through three repeat national cross sectional surveys conducted before (in 2010, 2014) and after (2018) the 2016 introduction of the European Union - Tobacco Product Directive (EU-TPD) and its transposition into Italy, and before Juul entered the Italian market in 2019. Prevalence of smoking and vaping, access to cigarettes and electronic cigarettes in adolescents aged 13-15 years were estimated from the 2010, 2014, and 2018 Global Youth Tobacco Surveys (N = 1587; N = 1428; N = 1518, respectively) conducted in Italy. Prevalence of current smokers and/or current vapers combined, accounting for dual users, non-significantly increased from 20.7% in 2010 to 27.9% in 2018. Although current smokers stalled around 20%, current vapers substantially increased from 0% in 2010, 7.4% in 2014, to 17.5% in 2018, and current exclusive vapers recorded an almost 3-fold significantly increase from 2.9% in 2014 to 8.2% in 2018. Moreover, 42% of ever vapers used nicotine-free electronic cigarettes, and only 5% of current users were frequent vapers (≥20 days in the past month). About 65% of current smokers and 76% of current vapers easily accessed to cigarettes or electronic cigarettes in 2018. After 2 years from its implementation in 2016, the EU-TPD does not seem to have slowed down the increase in vaping among Italian adolescents before Juul entered the Italian market. Additional research is needed in order to show a clear association between EU-TPD and changes in vaping and smoking in Italy and in the EU.

[Socioeconomic and regional inequalities in smoking cessation in Italy, 2014-2017]. / Disuguaglianze regionali e socioeconomiche nella cessazione del fumo in Italia, 2014-2017.

OBJECTIVES: to study regional differences in Italy of quit smoking attempts and of successful abstinence, in relation to socioeconomic status, cigarettes per day (cig/die), and smoking cessation method in a representative sample of the population resident in Italy. DESIGN: cross-sectional survey. SETTING AND PARTICIPANTS: in 2014-2017, PASSI survey (the ongoing Italian behavioural risk factor surveillancesystem) gathered data on smoking and sociodemographic characteristics of 35,157 smokers; 13,130 aged 18-69 years made >1 quit attempt in the previous year, 1,176 of them were successful quitters for >6 months. MAIN OUTCOME MEASURES: proportion of smokers who tried to quit; proportion of smokers who successfully quitted. RESULTS: about 35% of smokers made >1 quit attempt in the last year. Northern Italians and smokers with many economic difficulties were more likely to make a quit attempt, whereas heavy smokers were less likely. About 10% of attempters were abstinent for >6 months: from 6% in Campania and Abruzzo to 17% in the Bolzano province. Attempters who smoked <20 cig/die had higher likelihood to be abstinent, compared to those smoking <20 cig/die. Attempters with many economic difficulties had the lowest likelihood to be abstinent (7%), with no differences by region, educational level, quitting method. Attempters with no economic difficulties recorded the highest cessation rates (12%). Among them, those from Northern Italy, Tuscany, Marche, and Lazio (Central Italy), and Apulia (Southern Italy) compared to attempters from most Southern regions, and those with high education level or using traditional quitting methods compared to those using electronic cigarettes or unaided were more likely to be abstinent for >6 months. CONCLUSIONS: smokers with many economic difficulties in all Italy, and those with no economic difficulties residing in Umbria and in most Southern Italian regions, except for Basilicata and Puglia, recorded lower chances to quit. Regional differences may have two possible explanations integrating each other: Northern-Central regions are in a slightly more advanced stage in the tobacco epidemic; regions which developed specific tobacco control interventions in their Prevention Plans recorded higher quitting rates. Not-yet-implemented interventions could promote smoking cessation in smokers from Southern Italy and in those with lower socioeconomic status: reimbursement of smoking cessation treatments, a well-developed national Quitline linked to a webplatform and to mobile phone application or text-messaging, an opt-out smoking cessation service offered systematically to all smokers at every encounter in hospitals or health services.

[Development of a conceptual model for interpretation of monitoring indicators of cancer screenings from the Italian National Prevention Plan]. / Sviluppo di un modello concettuale di riferimento per l'interpretazione degli indicatori di monitoraggio degli screening oncologici nel Piano nazionale della prevenzione.

OBJECTIVES: the Italian National Prevention Plan (PNP) posed the standard to be achieved by Italian Regions for the implementation of cervical, breast, and colorectal cancer screening: to invite all of the target populations and to increase the screening uptake up to 50%, 60%, and 50%, respectively, the standard defined by the Essential Levels of Care (LEA). Moreover, for cervical cancer screening, it requires the implementation of HPV-DNA test and, for breast cancer screening, the PNP demands for the definition of diagnostic and follow up pathways for high familial risk women. The PNP also set up a monitoring system to assess the impact of implemented policies. A conceptual model has been defined to facilitate interpretation of variation in outcome indicators. DESIGN: after a systematic review, the DPSEEA (Driving forces, Pressure, State, Exposure, Effect, Actions) was identified as the more appropriate framework to assess the results of preventive policies. Factors for each component of the model were identified and indicators that allow measuring the changing of each of these factors were defined. RESULTS: among the "driving forces", the trust in the health care system and the social capital were included. The presence of opportunistic screening, the competing private clinical activity, the commitment of General Practitioners and "medical" leaders, the attitude to cooperation and to patients' involvement, and the level of agreement between the positions of scientific societies and the recommendations implemented in organized screening programmes were included in the "pressures". In "state", the availability of technological and human resources, the level of management skills and of accessibility were identified. The "exposure" was defined as the coverage of active invitation of the target population and the uptake of screening tests. The "exposure" factors influence the "effect", described as the impact on anticipation of cancer diagnosis, on disease incidence (for cervical and colorectal cancer) and prognosis. The changing in screening programs performance modifies the impact of invitation coverage and test uptake ("exposure"). CONCLUSIONS: through the DPSEEA framework, we set up a logical conceptual model, which includes implementable actions and the mechanisms through which these actions should impact on the "exposure" (invitation coverage and screening uptake) and on the screening performance (quality).

A long way to go: 20-year trends from multiple surveillance systems show a still huge use of tobacco in minors in Italy.

Background: Main aim was to describe youth smoking prevalence in Italy over the last two decades, and to provide recent trends in knowledge, attitudes towards smoking, awareness of anti-tobacco mass media campaigns, second-hand smoke (SHS) exposure and access to cigarettes. Methods: Figures from three surveillance systems, with 12 representative cross-sectional surveys (about 43 000 participants): European School Survey Project on Alcohol and Other Drugs, 15-16-year-old students, 1995-2015; Health Behaviour in School-aged Children, 11-, 13-, 15-year-old students, 2002-14 and Global Youth Tobacco Survey, 13-15-year-old students, 2010, 2014. Results: Among 11- and 13-year-old students, daily and non-daily smokers decreased by 30-50% from 2002 to 2014. Among 15-16-year-old adolescents, ever smokers significantly decreased by 10% in the period 1995-2015, whereas current and daily smokers have been stalling or even increased. Appeal of smoking increased in 2014 compared to 2010, perception of SHS as harmful, and awareness of recent anti-tobacco mass media campaigns decreased. Moreover, a significant 30% reduction in reporting retailers did not refuse to sell cigarettes to adolescents and a decrease in reporting to buy cigarettes were reported. Conclusions: Policies enforced in Italy over the last 20 years slightly reduced ever smokers, but did not decrease current and daily smokers in 15-16-year-old adolescents, and determined an impact among younger adolescents. Stricter rules on youth tobacco access reduced ease of access to cigarettes, but did not affect adolescents' tobacco use. Stronger tobacco control measures are urgently needed in order to determine a steeper decline in smoking prevalence in adolescents.

Electronic cigarette use as an aid to quit smoking in the representative Italian population PASSI survey.

This study explored electronic cigarette (e-cigarette) use as an aid to quit smoking and compared abstinence rates for different quitting methods in a representative sample of the Italian population. In the 2014-2015 PASSI survey, the ongoing Italian behavioural risk factor surveillance system, 6112 adults who smoked and made at least one quit attempt in the previous 12months, were categorized into three groups according to the method used in their most recent quit attempt: e-cigarette only, no aid, other quitting methods (medications; programmes delivered in smoking cessation services; other unspecified methods). The primary outcome was self-reported abstinence for a period ≥6months, adjusted for potential confounders. Eleven percent used e-cigarettes only, 86% no aid, 3% other quitting methods. Smoking abstinence was reported among 9% of those using no aid; 8% of e-cigarette users; 15% of those using other methods. No significant differences in abstinence were observed for e-cigarette users compared with those reporting no aid (adjusted Prevalence Ratio [aPR]=0.81; 95%Confidence Interval (CI)=0.58-1.14). Changing the reference group to e-cigarette users, those using other quitting methods were significantly more likely to report abstinence than e-cigarette users (aPR=1.76; 95%CI=1.07-2.88). One out of ten smokers who attempted to quit in 2014-2015 in Italy used e-cigarettes. E-cigarettes users were as likely to report abstinence as those using no aid, but were less likely to report abstinence than users of established quitting methods. Further studies are needed to understand the relationship between e-cigarette types used to quit and abstinence rates.

[Prevention of Chronic Kidney Disease and strategies to counteract chronic diseases in Italy]. / La prevenzione della malattia renale cronica e le strategie di contrasto alle malattie croniche in Italia.

The Prevention of Chronic Kidney Disease (CKD) is placed in the more general context of prevention of major chronic Non Communicable Diseases (NCDs): cardiovascular diseases, diabetes, chronic lung diseases and tumors that are the main problem for public health worldwide. Any health policy strategy aimed to the prevention of NCDs has to provide knowledge of health and socioeconomic status of the population, to reduce the level of exposure to risk factors and to adapt health services to the request for assistance. To this purpose, population monitoring systems have been implemented in the last years. The NCDs share some risk factors that are related, in large part, to unhealthy individual behaviours: smoking, alcohol abuse, unhealthy diet and physical inactivity. NCDs prevention has to be understood as the set of all actions, sanitary and not, aiming to prevent or delay the onset of diseases or their complications. Preventive measures should, therefore, involve not only the health sector but also all the actors that can help to prevent that disease. As for the Prevention of CKD, the Ministry of Health has established a working table, which handled the Drafting of the "Position paper for the CKD", approved in the State-Regions Conference on august 8th 2014. The document draws a national strategy to combat this disease through primary prevention, early diagnosis and the establishment of diagnostic - therapeutic pathways (DTP).

Smoking habits among italian adolescents: what has changed in the last decade?

Tobacco use, alcohol abuse, overweight and obesity are risk factors for numerous diseases in Italy as elsewhere. However, children and adolescents are not usually included in official national surveys although it is at this stage of life when unhealthy habits are often established. Italian participation in HBSC and GYTS surveys allows our country to implement standardized surveillance systems providing reliable information on tobacco-related behaviors of this population. Data from three HBSC surveys (2002-2010) show that following the drop in the first half of the decade, prevalence of tobacco use stabilized in the second half. The decline was significant for younger age groups, while prevalence of regular tobacco use remained stable among 15-year-olds. Many adolescents reported being exposed to secondhand smoke, to have at least one parent who smokes, and having seen teachers and students smoking at school. Although the sale of tobacco products to minors is prohibited, the vast majority had no trouble in buying cigarettes. Data from GYTS and HBSC surveys provide a wealth of information about attitudes and behaviors of Italian adolescents with respect to smoking. Despite some progress, sizeable gaps remain in meeting standard recommendations for discouraging smoking initiation and motivating adolescent smokers to quit the habit.

Compliance with the smoking ban in Italy 8 years after its application.

OBJECTIVES: The aim of this paper is to report compliance with the smoking ban and the spread of smoke-free homes after 3-8 years since the Italian smoking ban implementation, according to the ongoing Italian surveillance system for behavioural risk factors (PASSI). METHODS: PASSI is based on representative annual samples of the Italian population aged 18-69 years. We considered questions on smoking habits, self-reported compliance with the ban, and on smoke-free homes of 176,236 interviews conducted in 2008-2012. RESULTS: Ninety percent of respondents in 2012 reported that the smoking ban was enforced in hospitality premises (HPs), with a significant 3% increase from 2008. Similarly, 91.3% in 2012 reported a high compliance in workplaces other than HPs, with a significant 5% increase. Perception of compliance did not change among smokers and non-smokers. Seventy-eight percent of respondents in 2012 reported smoke-free homes, with a significant increase from 2008 to 2012. CONCLUSIONS: The high compliance with the ban that is still increasing even after 8 years since its implementation may partially have caused the concurrent increase in smoke-free homes.

Smoke-free policy development in Italy through the legislative process of the ban 2000-2005, and press media review 1998-2008.

The objective of this article is to describe the process of approval of the Italian smoking ban, enacted in 2005. The method is to conduct a review of proposed and approved legislation 2000- 2005, and of articles published in Italian newspapers, 1998-2008. Enabling factors in the process were: the leadership of two consecutive Health Ministers, both physicians, who introduced the bill four times between 2000-2002; the repeated presentation and final approval of the bill as an amendment within a bill on public administration which enabled timely approval of the ban; and the stringent air quality standards in the 2003 regulation that made building smoking rooms impracticable and prohibitively expensive. Limiting factors in the process were: the 6-month delay in approving the regulation on smoking rooms; the 1.5-year delay in approving the regulation establishing owners' responsibility for enforcing the ban in hospitality premises and the legal action in August 2005, which shifted responsibility for enforcement to police. Eighty-three percent of the 808 articles published on smoking in 1998-2008 were released between 2000-2005, during the policy process. While the press devoted considerable attention to the issues raised by the hospitality sector, the long legislative process of the bill and its regulations also stimulated coverage on tobacco control issues.